Extract
The epidemiology, treatment, and outcome assessment of neonatal brachial plexus palsy continue to be refined. Foad et al.1 analyzed the Kids' Inpatient Database from 1997, 2000, and 2003 to determine the incidence of neonatal brachial plexus palsy in the United States and additionally to determine the risk factors associated with brachial plexus palsy. In the United States, the incidence was at least 1.51 ± 0.02 cases per 1000 live births, but it decreased over the study period. The identified risk factors were shoulder dystocia (100 times increased risk), exceptionally large birth weight (4.5 kg) (fourteen times increased risk), and forceps delivery (nine times increased risk). On the other hand, twin or multiple births and cesarean section delivery appeared to have a protective effect. There appeared to be other unknown factors that influenced the incidence of brachial plexus palsy as only 46% of all children with this condition had one or more of these risk factors. In fact, 56% of brachial plexus palsies were not associated with a difficult delivery. Finally, the only reliable predictor of shoulder dystocia was a previous episode of shoulder dystocia in the mother.
The epidemiology, treatment, and outcome assessment of neonatal brachial plexus palsy continue to be refined. Foad et al.1 analyzed the Kids' Inpatient Database from 1997, 2000, and 2003 to determine the incidence of neonatal brachial plexus palsy in the United States and additionally to determine the risk factors associated with brachial plexus palsy. In the United States, the incidence was at least 1.51 ± 0.02 cases per 1000 live births, but it decreased over the study period. The identified risk factors were shoulder dystocia (100 times increased risk), exceptionally large birth weight (4.5 kg) (fourteen times increased risk), and forceps delivery (nine times increased risk). On the other hand, twin or multiple births and cesarean section delivery appeared to have a protective effect. There appeared to be other unknown factors that influenced the incidence of brachial plexus palsy as only 46% of all children with this condition had one or more of these risk factors. In fact, 56% of brachial plexus palsies were not associated with a difficult delivery. Finally, the only reliable predictor of shoulder dystocia was a previous episode of shoulder dystocia in the mother.
The treatment paradigm for brachial plexus birth palsy continues to evolve. In addition to restoring function with surgical techniques such as microsurgical nerve reconstruction, soft-tissue release, tendon transfers, and humeral osteotomy, it is becoming increasingly clear that, in order to achieve a good long-term outcome, joint stability and integrity may need to be maintained. With use of magnetic resonance imaging or computed tomography scans, Waters and Bae2 demonstrated that, in patients with preexisting glenoid deformity, appropriately timed open reduction of the glenohumeral joint combined with musculotendinous lengthenings and tendon transfers can remodel the glenoid version and humeral head subluxation. As expected, this improvement in joint morphology was also associated with improved clinical outcomes. Whether this improvement in joint morphology will lead to improved outcomes over the long term remains to be demonstrated.
Pediatric trigger thumb is a common upper extremity disorder. Definitive treatment of this condition is often operative, especially in patients older than three years of age, because of concerns regarding persistent contractures. The rate of spontaneous resolution of this condition is variable, but it has been noted to be higher when the condition presents at birth. Baek et al.3 prospectively followed seventy-one thumbs in fifty-three children over a course of two to twelve years with use of serial examinations. The median age of this cohort was twenty-three months at the time of the initial visit. The authors demonstrated that the condition resolved spontaneously in 63% of the thumbs, with the median time from the initial visit to resolution being forty-eight months. Furthermore, even in thumbs in which the condition did not spontaneously fully resolve, the flexion deformity appeared to decrease over time. That study provides data that may be useful when the options of operative and nonoperative treatment of pediatric trigger thumb are discussed with the family.
In the adult population with acetabular dysplasia, there often is no childhood history of developmental dysplasia of the hip. This raises the questions of how and when these cases of occult dysplasia develop. Song et al.4 retrospectively reviewed all radiographs of children who were managed for developmental dysplasia of the hip in infancy and were followed until maturity. The prevalence of bilateral infant developmental dysplasia of the hip was 42%. Of the contralateral hips that did not have contralateral dysplasia during infancy, 40% had evidence of mild acetabular dysplasia at maturity. It appears that in patients with developmental dysplasia of the hip, the contralateral hip that does not have any radiographic evidence of dysplasia in infancy is still at some risk for the development of mild acetabular dysplasia in adulthood. This suggests that there may be some developmental factors in adolescence responsible for the development of mild acetabular dysplasia. When adult acetabular dysplasia becomes symptomatic, the treatment options are a pelvic osteotomy or an arthroplasty. Although not well studied, nonoperative therapy appears to be ineffective. In this context, Sharifi et al.5 analyzed the cost-effectiveness of periacetabular osteotomy as compared with arthroplasty for the treatment of hip dysplasia. The authors found that for Tönnis grade-1 hips (those with minimum radiographic evidence of osteoarthritis), the periacetabular osteotomy was cost-effective if the hip survived 5.5 years and cost-saving if it survived 10.8 years. Sensitivity analysis further demonstrated that periacetabular osteotomy was the preferred treatment in all tested scenarios. For Tönnis grade-2 hips (those with moderate joint-space narrowing), the osteotomy became cost-effective after 18.25 years. These findings highlight the importance of careful counseling and patient selection, especially in cases in which the patient has some radiographic evidence of arthritis of the hip.
In the treatment of slipped capital femoral epiphysis, the role of prophylactic pinning of the contralateral side remains controversial. Yildirim et al.6, in a study of 227 patients with a unilateral slipped capital femoral epiphysis, characterized the complications resulting from a contralateral slipped capital femoral epiphysis. The authors noted that 36% of the patients had development of a contralateral slipped capital femoral epiphysis within a mean of 6.5 months. Of the eighty-two contralateral slips, eighteen were of moderate to severe severity and five were associated with the development of osteonecrosis or chondrolysis. All hips that had development of chondrolysis had a severe slipped capital femoral epiphysis, and the one hip that had development of osteonecrosis was unstable. Furthermore, the average age of the patients who had development of a contralateral slipped capital femoral epiphysis was significantly lower than that of the patients who did not (11.2 compared with thirteen years). All of these data appear to be consistent with information already in the literature. More importantly, and very rationally, the authors utilized the data in combination with prior decision analysis regarding prophylactic pinning and concluded that for their population, prophylactic pinning of the contralateral hip was warranted.
Legg-Calvé-Perthes disease remains a challenging condition to treat. It is generally agreed that hinge abduction in patients with this disease is associated with a poor prognosis. However, a clear radiographic definition has been elusive. A definition of hinge abduction should include two criteria: widening of the medial joint space in abduction and impingement of the deformed femoral head onto the lateral lip of the acetabulum in abduction. Nakamura et al.7 attempted to refine the definition of hinge abduction by using quantitative measures such as a subluxation index and an impingement sign. Although that study did not document the inter-rater and intra-rater variability of this definition of hinge abduction, this study is a first step toward an improved definition of this often used radiographic sign. The treatment of hinge abduction in patients with Legg-Calvé-Perthes disease continues to be variable and ranges from shelf arthroplasty to valgus osteotomy to cheilectomy. This variability is somewhat due to varying treatment goals and varying stages of the disease. In an uncontrolled cohort study, Freeman et al.8 demonstrated that when some remodeling potential is still present in the femoral head, shelf arthroplasty can be effective for achieving improved radiographic metrics. In the older population with hinge abduction, valgus osteotomy appears to be effective for improving patient outcomes9. Legg-Calvé-Perthes disease remains a subject of much controversy that demands more precise disease staging and improved noninvasive imaging tools to follow shape changes in both the cartilaginous and osseous components of the hip joint in the early phase.
Self-reported outcome instruments, including generic health surveys such as the Short Form-36 (SF-36), are increasingly being used to assess the outcome of our surgical interventions. Huffman et al.10 demonstrated that the normative SF-36 values for intercollegiate athletes differ from the age and sex-matched normative values for the general population. That study further highlighted the bias that may be present if only the postoperative outcome metrics are used in isolation. If instruments such as the SF-36 are to be used, having preoperative and postoperative values is essential. Furthermore, the appropriate normative values must be used for comparison.
The indications for hip arthroscopy continue to broaden as the technique improves. Philippon et al.11 reported on a small series of young patients (age range, eleven to sixteen years) who underwent arthroscopic treatment of femoroacetabular impingement. In addition to soft-tissue débridement such as labral resection and chondroplasty, osseous débridement of the acetabular rim and femoral head-neck junction was performed. The authors reported significantly improved outcomes in this nonrandomized uncontrolled cohort study. Unlike the adult population, there were no cases of end-stage full-thickness loss (Outerbridge grade-IV) chondromalacia that required microfracture. However, trimming of the acetabular rim with detachment and refixation of the labrum was performed in fourteen of sixteen patients. The original indication for labral takedown and acetabular rim trimming was to treat acetabular overcoverage in the presence of cartilage delamination at the labral-chondral junction. With the recent improvements in arthroscopic technique, the indications for many of these arthroscopic procedures such as acetabular rim resection are being broadened. A larger randomized study is truly needed to sort out the importance of simple soft-tissue débridement as opposed to combined soft-tissue and osseous débridement in these hips. However, it is becoming clear that, as is the case in the knee, athletic injury can lead to early chondral damage even in the adolescent hip.
Acute patellar dislocations are common in the pediatric and adolescent age groups. Palmu et al.12 compared the efficacy of operative and nonoperative treatment of this condition in a prospective randomized clinical trial. Over a two-year enrollment period, seventy-four patients with acute patellar dislocations were randomized to operative or nonoperative treatment. The patients in the operative arm underwent repair of the medial retinacular structures, usually with a lateral release if the patella was dislocatable or with only a lateral release if the patella was not dislocatable with the patient under anesthesia. The postoperative care was identical for both arms in this randomized study. No sham surgery was performed, so the patients were not blinded to the randomization. At an average of six years, the rate of follow-up by an independent observer was 94% and the authors demonstrated that the results of operative and nonoperative treatment of acute patellar dislocation were equivalent. The redislocation rate was approximately 70% in both arms of the study. Despite this finding, a good clinical outcome was achieved in 75% of the patients in both arms of the study. The single predictor of recurrent dislocation was a positive family history of patellar instability.
Two recent reports presented the results of reconstruction for the treatment of late-developing cavus deformities occurring after extensive soft-tissue releases in patients with idiopathic clubfoot. Yong et al.13 reported good improvement in patients with dorsal bunions who were managed with proximal transfer of the flexor hallucis longus in combination with a first metatarsal osteotomy. In the report by Weiner et al.14, more proximal and severe cavus deformities were salvaged with use of a midfoot dome osteotomy that was especially designed to correct three-dimensional deformities. That large review of 139 painful and rigid feet revealed a satisfactory result in 76% of the children.
The last ten years have seen a resurgence in nonoperative methods for the treatment of idiopathic clubfoot. Equal numbers of good results can be expected in association with either the Ponseti method or the French physiotherapy approach15. Other reports at the Pediatric Orthopaedic Society of North America (POSNA) annual meeting demonstrated that the Ponseti method may be extended to children with teratologic or arthrogrypotic clubfoot deformities, although a greater number of casts are needed16.
The treatment of bunion in juvenile patients has been a challenging enterprise because of high rates of recurrence and the morbidity of using "adult" procedures on growing feet. Applying the principles of guided growth for the correction of limb deformity, Davids et al.17 utilized lateral hemiepiphyseodesis of the great-toe metatarsal to treat the juvenile bunion. In a retrospective review, they demonstrated no further progression of the deformity in all of the feet and improvement in the deformity in half of the feet. Given that this procedure is associated with low risk and minimum morbidity, these results seem to justify its use for the treatment of progressive and painful deformities, especially when compared with the results of more traditional surgical approaches.
Recreational use of all-terrain vehicles continues to result in high numbers of substantial injury in both children and adolescents. Two large reviews from Arkansas and Kentucky demonstrated an increased incidence of these injuries during and after expiration of the 1988 Consent Decrees from the United States Consumer Product Safety Commission18,19, which mandated a ban on three-wheel all-terrain vehicles, required retailers to provide rider safety equipment and training, required extensive warning labels on all-terrain vehicles, and prohibited the sale of adult-sized vehicles to children under the age of thirteen years. A preponderance of head injuries and long-bone injuries occur in riders under the age of sixteen years, and both the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons have recommended that no individual who is less than sixteen years of age should operate these machines.
The femur is the most commonly fractured long bone, and a host of different surgical options can be chosen, depending on the age and size of the patient, the pattern and location of the fracture, and the degree of comminution. Flexible intramedullary nailing is a mainstay of treatment for many of these fractures. Wall et al.20 compared stainless steel and titanium nails and found superior results (less malunion) in association with the cheaper stainless steel implants. A recent retrospective cohort study of open femoral fractures established that flexible intramedullary nailing is superior to external fixation in terms of complication rates21. As an alternative to external fixation, locked plate fixation has also demonstrated good results for difficult femoral fracture patterns22. Although most pediatric tibial fractures are treated with nonoperative methods, operative fixation is occasionally needed for open fractures. External fixation of these challenging fractures has been shown to be associated with a higher rate of complications (nonunion and malunion) in comparison with flexible nailing, which has been associated with better results23.
Redisplacement of distal radial fractures after closed reduction and casting is common and is more likely to be seen in association with complete fracture displacement and >30° of fracture obliquity as well as with poor molding of the cast24. Should redisplacement occur during standard weekly follow-up, a variety of pin constructs appear to provide stable fixation equally well25. Galeazzi fractures in children are rare and may go undiagnosed, but, in a comprehensive study of these injuries, good function of the distal radioulnar joint was achieved in 90% of the children when fracture reduction was achieved and maintained in a short or long-arm cast26. Forearm fractures are predominantly treated with closed methods, with good results; however, refractures can occasionally occur, and a recent large analysis revealed that most refractures occur through previous fracture sites in the proximal and middle thirds of the forearm and within ten months after the initial injury27. In half of those cases, a fracture line was still visible on the latest follow-up radiograph. The authors suggested longer immobilization for proximal forearm fractures, especially if incomplete healing is present. Operative fixation of forearm fractures is reserved predominantly for open and unstable injuries with unacceptable alignment, and it continues to appear that equally good results can be obtained with either flexible nailing or plate fixation28.
In a level-I trial, Yen and Kocher found that, following closed reduction, displaced supracondylar humeral fractures can be treated with a variety of pin constructs (medial and lateral pins as opposed to all lateral pins), with equivalent results29. Higher degrees of malunion may be expected if there is =10° of coronal plane or =20° of sagittal plane fracture obliquity30. This is in contrast to distal humeral metaphyseal-diaphyseal fractures, where increased fracture obliquity leads to better results than unstable transverse fractures31. Finally, Halanski et al.32 evaluated the risk of thermal injury associated with contemporary casting techniques. They noted that thermal injury is associated with thick plaster and a water temperature of >24°C or when a curing cast is over-wrapped with fiberglass or placed on a pillow.
In fracture treatment, adequate pain control without increasing the risk of complications such as compartment syndrome is an important part of quality modern-day care. Wathen et al.33, in a prospective, randomized, controlled trial, demonstrated that fascia iliaca compartment block provides more effective pain control for femoral fractures than intravenous morphine does. The fascia iliaca compartment is located anterior to the iliacus muscle within the pelvis. It is bound superolaterally by the iliac crest and medially merges with the fascia overlying psoas muscle. Both the femoral nerve and the lateral cutaneous nerve of the thigh lie under the iliacus fascia in their intrapelvic course. In fifty-six pediatric patients, the fascia iliaca compartment block was administered by the emergency department physicians with use of surface landmarks for acute pain control. The pain scores were followed serially for as long as six hours, and potential complications from the block and intravenous morphine were monitored. The fascia iliaca compartment block provided rapid and improved pain control in this group, without evidence of increased complications. Similarly, White et al.34, in a prospective, randomized, controlled trial with forty-two patients with an ankle fracture-dislocation, demonstrated that the placement of an intra-articular block can be achieved more rapidly than the administration of conscious sedation. The pain relief afforded by both techniques was equivalent, as was the reduction quality.
Intrathecal baclofen pumps have been used with increasing frequency and success for patients with cerebral palsy with severe spasticity and dystonia in the upper and lower extremities who are unable to walk35,36. It remains controversial whether intrathecal baclofen pumps have any effect on the natural history of scoliosis progression in patients with severe cerebral palsy. Senaran et al.37 found no increase in the expected curve progression in patients with cerebral palsy after intrathecal baclofen placement, whereas Ginsburg and Lauder38 documented a significant increase in curve progression. As a result, it is important that patients with scoliosis be appropriately monitored. If curve progression is noted, surgical correction can be effective, as was recently reported in a large series of patients with cerebral palsy39.
Many patients with cerebral palsy who are unable to walk have progressive hip instability, which can be halted with muscle and tendon releases. Should progression of displacement continue, hip reconstruction (by means of femoral and/or pelvic osteotomy) may become necessary. Botulinum toxin A has been injected into the adductor muscles to treat hips at risk, and the results of a recent level-I trial justified its use as a method to delay hip displacement40. Botulinum toxin A is also effective for the treatment of spastic equinus, especially if casting is delayed after its injection41.
Finally, it appears that the epidemic of childhood obesity is affecting children who have cerebral palsy. In a retrospective analysis, Rogozinski et al.42 documented a significant increase in weight, especially among children who are less than eight years of age, who have less severe involvement, and who are female. This problem may become a burden to those wishing to remain able to walk over time.
Lower extremity deformity can be assessed either with standing full-length radiographs or intraoperatively with supine fluoroscopy by stretching a cautery cord from the hip to the ankle center. These two techniques appear to be equally effective, provided that the amount of initial limb deformity is <2 cm of mechanical axis deviation and the patient is not obese43. The same researchers also noted that the presence of a ring fixator on the leg will alter how the patient stands, and, in this case, standing radiographs will not represent the true alignment.
Limb lengthening by means of external fixation can be a challenge, and efforts have been made to develop internal-only lengthening devices. One report on the use of a novel motorized nail in adolescents demonstrated more rapid healing than is observed in association with external fixation44. The authors reported a lower complication rate in the eight limbs that were lengthened with the motorized device in comparison with the findings described in published reports on two other mechanical intramedullary lengthening devices. Comparative studies are needed to confirm that a motorized device is better (in terms of improved patient comfort and lower complication rates) than mechanical intramedullary devices, which require external manipulation.
Congenital pseudoarthrosis of the tibia remains a challenging condition to treat. When a patient presents with deformity and dysplastic changes of the tibia but without fracture, osteotomy or curettage and bone-grafting may produce unacceptably high rates of nonunion. For this subset of patients, the treatment options include bracing or allograft bypass grafting to prevent fracture. Ofluoglu et al.45 presented the long-term follow-up results of bypass grafting in ten patients. In that small series, none of the patients had development of a pseudoarthrosis of the tibia. Although the study was an uncontrolled case series, the authors noted that, in their experience, brace treatment for Crawford type-2 tibial dysplasia was associated with unacceptable rates of fracture and pseudoarthrosis. All patients except one had a minimum leg-length discrepancy; however, the majority had a residual deformity of the tibia and a compensatory deformity at the knee, which required later surgical correction. In some patients with congenital pseudoarthrosis of the tibia, proximal tibial limb lengthening may be considered to correct a leg-length discrepancy, but at the risk of poor regenerate healing. Cho et al.46 reviewed a large series of patients and found that acceptable bone-healing could be expected if distraction osteogenesis was performed proximally in nondysplastic bone that had not had previous surgery. Limb lengthening through this bone may be justified in this high-risk group.
Lengthening short upper extremity stumps is another challenging clinical problem, with little information having been published in the literature until a recent report by Bernstein et al.47. Those authors demonstrated a significant increase in length, although a number of additional surgical procedures were required to treat complications such as poor distal soft-tissue coverage. While eight of nine patients could be fitted with a prosthesis, the authors honestly pointed out that some patients did not use the device and thus questioned the cost-versus-actual-benefit ratio.
The treatment of elbow contractures in patients with arthrogryposis has been controversial. In a recent multicenter review of twenty-nine elbows that were treated with posterior release and triceps lengthening, the mean increase in elbow flexion was a modest 36°, yet, importantly, all of the patients could reach the hand to the mouth with passive assistance48. As a result, the authors advocated simple posterior release and triceps lengthening without tendon transfer to provide active elbow flexion.
Thankfully, most neoplastic lesions in children are benign. They are usually discovered serendipitously or as a result of fracture or pain. However, one must be vigilant as a recent evaluation demonstrated that musculoskeletal pain and radiographic abnormalities were the presenting symptoms in 40% of 122 patients with pediatric leukemia49. Osteoid osteoma is a benign tumor that often presents with pain. Moser et al.50, in a study of sixty-eight children who were managed with laser ablation, reported a 98% success rate after one or two procedures. Osteoblastoma is a rare tumor for which Arkader and Dormans51 advocated a four-step approach for removal. The authors found that extensive curettage, high-speed burring, and chemical and thermal cautery were effective for removing these tumors in fourteen of fifteen children.
Aneurysmal bone cysts and unicameral bone cysts are commonly encountered benign tumors that can present therapeutic challenges because of high recurrence rates. A multicenter randomized clinical trial comparing bone marrow and steroid injections into these cysts was recently published52. A low rate of healing was noted radiographically in association with both methods, although cysts that had been injected with steroids healed significantly more often than those that had been injected with bone marrow (42% compared with 23%). Probably more importantly, though, there was no difference in the risk of refractures, which was about 25% in both groups. Aneurysmal bone cysts that are treated with intralesional curettage are more prone to recur than unicameral bone cysts, with recurrence rates generally reported to be between 10% and 30%. Two recent studies demonstrated higher recurrence rates in patients younger than five years of age (55%)53 and in patients with a juxtaphyseal tumor (42%)54. Despite the higher recurrence rate, those authors recommended prudence when considering aggressive surgical resection, which may destroy the growth potential of the limb, as the morbidity resulting from repeat curettage is less than that resulting from a shortened or malformed limb.
As reported in a large series from the Children's Medical Center of Dallas, there continues to be an increase in the rate of methicillin-resistant Staphylococcus aureus osteomyelitis in children55. In a consecutive series spanning 1999 to 2003, the authors demonstrated that 23% of all patients had a methicillin-resistant Staphylococcus aureus infection. A fivefold increase in comparison with the rate of methicillin-sensitive Staphylococcus aureus infections was noted in the later half of the study period. Children with a methicillin-resistant Staphylococcus aureus infection tended to have higher inflammatory parameters, longer hospitalization and antibiotic needs, and a greater number of complications than those with a methicillin-sensitive Staphylococcus aureus infection.
Gafur et al.56 clearly demonstrated that, in comparison with twenty years ago, the epidemiology of musculoskeletal infections in the Dallas area has clearly changed. The per capita incidence of osteomyelitis increased 2.8-fold, whereas the incidence of septic arthritis did not. Methicillin-resistant Staphylococcus aureus was isolated as the causative organism in 30% of children, whereas twenty years ago this organism was a rare cause of osteomyelitis. Additionally, the incidences of pyomyositis and deep soft-tissue abscesses increased, as did those of multifocal osteomyelitis and complications resulting from infections such as deep venous thrombosis and septic thrombophlebitis. As the epidemiology changes to a more aggressive form of infection, the therapeutic approach should adapt as well, and Gafur et al. recommended more aggressive early débridement, closer surveillance for deep venous thrombosis, and an appropriate and adequate duration of antibiotic therapy.
Traditionally, culture specimens from infected joints have been associated with a high false-negative rate. Therefore, a rapid, highly sensitive and specific test for live bacteria in synovial fluid has the potential to improve the treatment of septic arthritis. Birmingham et al.57 devised a real-time quantitative reverse transcription polymerase chain reaction test that has a 0% false-negative rate and a detection limit of 100 to 1000 bacteria/100 µL. The test is rapid and can provide results in five hours or less. The specificity of this test was achieved by targeting the bacterial genes groEL or femC. The groEL gene encodes a heat shock protein that is essential for bacterial growth, and the femC gene of Staphylococcus is functionally required for methicillin resistance. These two genes are closely related to the viability of bacteria or greatly downregulated in response to bacterial death and hence should provide specificity for the detection of viable bacteria. Additional work in the clinical setting is required to validate this test; however, this method of detecting live bacteria, in combination with described methods of using polymerase chain reaction-based molecular detection to determine species and antibiotic sensitivity, has the potential to dramatically improve the diagnosis and treatment of septic arthritis.
Recent in vitro studies have shown that even brief exposure to bupivacaine may cause apoptosis of chondrocytes, which may result in chondrolysis. Although adverse clinical events resulting from intra-articular bupivacaine use have not been demonstrated, the theoretical risk motivated Piper and Kim58 to compare the toxicity of ropivacaine and bupivacaine on chondrocytes. Those authors demonstrated, with use of human cartilage explants, that exposure to 0.5% bupivacaine for thirty minutes resulted in an approximately 22% decrease in chondrocyte viability as compared with that in controls that had been exposed to saline solution. In contrast, exposure to ropivacaine for the same duration did not have any adverse effect. Additional studies are necessary to determine if this in vitro finding has clinical relevance.
Magnetic resonance imaging of cartilage continues to advance. T1rho-weighted magnetic resonance imaging is a noncontrast imaging technique that is designed to measure water and extracellular matrix interactions. In cartilage, this sequence has shown correlations with tissue proteoglycan content, in a fashion similar to the delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) technique. In avascular tissue such as the nucleus pulposus, a noncontrast technique such as T1rho-weighted magnetic resonance imaging would have a distinct advantage over a contrast technique such as dGEMRIC. Nguyen et al.59, with use of cadaveric human spine specimens, demonstrated that T1? relaxation times correlated with the tissue-swelling pressure, glycosaminoglycan content, and hydration but not with the modulus or the permeability of intervertebral disc. The goal of that study was to utilize this biochemical imaging technique to detect early disc degeneration. Although the number of specimens was limited, this preliminary study appeared to demonstrate that T1? relaxation times were correlated with the presence of disc degeneration. Additional clinical studies are necessary to demonstrate the value of this imaging technique in clinical practice or clinical research.
Back Pain
Some recent work has been done to streamline and validate the methods used to identify patients with mechanical low-back pain. Auerbach et al.60 retrospectively studied 100 consecutive pediatric patients with low-back pain and found that painless hyperextension combined with a negative magnetic resonance imaging scan and normal radiographic findings was predictive of mechanical pain. For patients without neurological signs and symptoms and with pain for less than six weeks, a bone scan is the most useful screening test. A similar strategy was utilized in a prospective study wherein bone scanning was used in all patients with non-neurological pain, normal findings on physical examination, and normal blood tests61. The authors found that 78% of the patients had mechanical back pain, and magnetic resonance imaging did not improve the diagnosis rate unless neurological symptoms were present.
Nonoperative Treatment of Scoliosis
Jarvis et al.62 recently reported the results of nighttime bracing in patients with juvenile idiopathic scoliosis. They believed that the successful management of 50% of the patients in the study was an improvement in comparison with the natural history of this condition, which has a high risk for progression. They hypothesized that part-time brace wear may improve compliance in these patients, thus improving the ultimate effectiveness of bracing. Two recent studies assessed the validity of compliance monitors for brace wear among patients with adolescent idiopathic scoliosis; temperature-based monitors correlated better with self-reported logs of thoracolumbosacral orthosis use than did pressure-based monitors63. However, with use of the former technology, it appeared that patients only wore the brace 47% of the time in comparison with physician, parent, orthotist, and patient estimates of approximately 70% of the prescribed time.
Operative Treatment of Scoliosis
Scoliosis may result from the presence of a syrinx or a Chiari malformation. Patients with a syrinx or a Chiari malformation are usually male, have an early onset of scoliosis, and may have symptoms or signs of neurological compromise. Radiographically, atypical curves (including thoracic kyphosis, left thoracic curves, and spinal imbalance) are seen in approximately two-thirds of the patients64,65. The surgical management of these patients is associated with higher rates of neurological complications, and curve progression after fusion recently was reported in 36% of patients with a syrinx64.
The effectiveness of spinal cord monitoring during spinal deformity surgery was recently reported in two large studies (involving >1000 patients), with the incidence of spinal cord injury approaching 1%66,67. Transcranial motor-evoked potentials are exquisitely sensitive to threatened spinal cord function, and their use together with traditional somatosensory evoked potentials improves the accuracy of spinal cord monitoring. Somatosensory evoked potentials may not detect all problems and may not detect problems as rapidly as transcranial motor-evoked potentials do67, and the sensitivity of transcranial motor-evoked potentials has led some centers to abandon somatosensory evoked potentials in favor of motor monitoring alone. For instance, Hsu et al.68 reported 100% sensitivity for the detection of a clinically important neurological event in a consecutive series of 144 patients. The authors defined a neurological event as either a new postoperative deficit or a 50% decrease in the monitoring potential over a one-minute period. The rapidity with which motor monitoring detects spinal cord compromise makes it a valuable tool for sagittal plane correction, and prompt detection of a problem can lead to its resolution before a permanent deficit results69,70.
The systems described by King and Lenke for the classification of adolescent idiopathic scoliosis have been used to determine what portions of the spine are excessively rigid and require instrumentation. Both systems appear to be equally useful for helping to determine distal fusion levels and for identifying patients who are candidates for selective thoracic fusion71. Selective thoracic fusion can be performed either anteriorly or posteriorly, and there does not appear to be any difference in the amount of lumbar correction achieved72.
Recently, less anterior scoliosis surgery has been done because of the corrective power of pedicle screw constructs and surgical methods designed to improve flexibility, such as posterior release, posterior osteotomy, and vertebral resection. Furthermore, we have become more aware of the effect of anterior surgery on pulmonary function. Specifically, improvement in pulmonary function can be expected following posterior thoracic spine fusion73, whereas anterior deformity surgery can result in diminished pulmonary function. In a study by Kim et al.74, the thoracoabdominal approach and instrumentation for thoracolumbar or lumbar curves did not affect pulmonary function to the degree that rib resection and thoracotomy did for thoracic curves. With use of pedicle screw constructs, surgeons are able to correct severe scoliosis deformities with improved radiographic results75 in comparison with non-screw constructs76. The appropriate use of pedicle screws has resulted in 50% to 66% curve correction, with good maintenance of the curve correction for a minimum of three years77.
The improvement in health-related quality of life following surgery for the treatment of adolescent idiopathic scoliosis is small and is not significant in comparison with that in patients in whom scoliosis is treated with observation78. Whether the quality of life will improve over time remains to be seen, yet both short-term and theoretical long-term benefits need to be balanced by the surgical complication rates. In a recent prospective multicenter study, the incidence of non-neurological complications was 15.4%, with higher rates being seen in patients with renal disease and in patients in whom the surgical procedures were longer and resulted in greater blood loss79. An increased complication rate was not seen in patients who had an elevated body mass index79,80 or in cases in which the surgery was performed with a less experienced surgical assistant81. Finally, pseudoarthrosis is a known complication, but it did not seem to be associated with the use of ketorolac82.
Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am.2008;90:1258-64.901258
2008
[PubMed][CrossRef]
Waters PM, Bae DS. The early effects of tendon transfers and open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy. J Bone Joint Surg Am.2008;90:2171-9.902171
2008
[CrossRef]
Baek GH, Kim JH, Chung MS, Kang SB, Lee YH, Gong HS. The natural history of pediatric trigger thumb. J Bone Joint Surg Am.2008;90:980-5.90980
2008
[CrossRef]
Song FS, McCarthy JJ, MacEwen GD, Fuchs KE, Dulka SE. The incidence of occult dysplasia of the contralateral hip in children with unilateral hip dysplasia. J Pediatr Orthop.2008;28:173-6.28173
2008
[CrossRef]
Sharifi E, Sharifi H, Morshed S, Bozic K, Diab M. Cost-effectiveness analysis of periacetabular osteotomy. J Bone Joint Surg Am.2008;90:1447-56.901447
2008
[CrossRef]
Yildirim Y, Bautista S, Davidson RS. Chondrolysis, osteonecrosis, and slip severity in patients with subsequent contralateral slipped capital femoral epiphysis. J Bone Joint Surg Am.2008;90:485-92.90485
2008
[CrossRef]
Nakamura J, Kamegaya M, Saisu T, Kenmoku T, Takahashi K, Harada Y. Hip arthrography under general anesthesia to refine the definition of hinge abduction in Legg-Calvé-Perthes disease. J Pediatr Orthop.2008;28:614-8.28614
2008
[CrossRef]
Freeman RT, Wainwright AM, Theologis TN, Benson MK. The outcome of patients with hinge abduction in severe Perthes disease treated by shelf acetabuloplasty. J Pediatr Orthop.2008;28:619-25.28619
2008
[CrossRef]
Myers GJ, Mathur K, O'Hara J. Valgus osteotomy: a solution for late presentation of hinge abduction in Legg-Calvé-Perthes disease. J Pediatr Orthop.2008;28:169-72.28169
2008
[CrossRef]
Huffman GR, Park J, Roser-Jones C, Sennett BJ, Yagnik G, Webner D. Normative SF-36 values in competing NCAA intercollegiate athletes differ from values in the general population. J Bone Joint Surg Am.2008;90:471-6.90471
2008
[CrossRef]
Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop.2008;28:705-10.28705
2008
[CrossRef]
Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg Am.2008;90:463-70.90463
2008
[CrossRef]
Yong SM, Smith PA, Kuo KN. Dorsal bunion after clubfoot surgery: outcome of reverse Jones procedure. J Pediatr Orthop.2007;27:814-20.27814
2007
[CrossRef]
Weiner DS, Morscher M, Junko JT, Jacoby J, Weiner B. The Akron dome midfoot osteotomy as a salvage procedure for the treatment of rigid pes cavus: a retrospective review. J Pediatr Orthop.2008;28:68-80.2868
2008
[CrossRef]
El-Hawary R, Karol LA, Jeans KA, Richards BS. Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique. J Bone Joint Surg Am.2008;90:1508-16.901508
2008
[CrossRef]
Boehm S, Limpaphayom N, Alaee F, Sinclair MF, Dobbs MB. Early results of the Ponseti method for the treatment of clubfoot in distal arthrogryposis. J Bone Joint Surg Am.2008;90:1501-7.901501
2008
[CrossRef]
Davids JR, McBrayer D, Blackhurst DW. Juvenile hallux valgus deformity: surgical management by lateral hemiepiphyseodesis of the great toe metatarsal. J Pediatr Orthop.2007;27:826-30.27826
2007
[CrossRef]
Kirkpatrick R, Puffinbarger W, Sullivan JA. All-terrain vehicle injuries in children. J Pediatr Orthop.2007;27:725-8.27725
2007
[CrossRef]
Kute B, Nyland JA, Roberts CS, Hartwick-Barnes V. Recreational all-terrain vehicle injuries among children: an 11-year review of a Central Kentucky level I pediatric trauma center database. J Pediatr Orthop.2007;27:851-5.27851
2007
[CrossRef]
Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am.2008;90:1305-13.901305
2008
[CrossRef]
Ramseier LE, Bhaskar AR, Cole WG, Howard AW. Treatment of open femur fractures in children: comparison between external fixator and intramedullary nailing. J Pediatr Orthop.2007;27:748-50.27748
2007
[CrossRef]
Hedequist D, Bishop J, Hresko T. Locking plate fixation for pediatric femur fractures. J Pediatr Orthop.2008;28:6-9.286
2008
[CrossRef]
Srivastava AK, Mehlman CT, Wall EJ, Do TT. Elastic stable intramedullary nailing of tibial shaft fractures in children. J Pediatr Orthop.2008;28:152-8.28152
2008
[CrossRef]
Alemdaroglu KB, Iltar S, Cimen O, Uysal M, Alagöz E, Atlihan D. Risk factors in redisplacement of distal radial fractures in children. J Bone Joint Surg Am.2008;90:1224-30.901224
2008
[CrossRef]
Jung HJ, Jung YB, Jang EC, Song KS, Kang KS, Kang SY, Lee JS. Transradioulnar single Kirschner-wire fixation versus conventional Kirschner-wire fixation for unstable fractures of both of the distal forearm bones in children. J Pediatr Orthop.2007;27:867-72.27867
2007
[CrossRef]
Eberl R, Singer G, Schalamon J, Petnehazy T, Hoellwarth ME. Galeazzi lesions in children and adolescents: treatment and outcome. Clin Orthop Relat Res.2008;466:1705-9.4661705
2008
[CrossRef]
Baitner AC, Perry A, Lalonde FD, Bastrom TP, Pawelek J, Newton PO. The healing forearm fracture: a matched comparison of forearm refractures. J Pediatr Orthop.2007;27:743-7.27743
2007
[CrossRef]
Reinhardt KR, Feldman DS, Green DW, Sala DA, Widmann RF, Scher DM. Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children. J Pediatr Orthop.2008;28:403-9.28403
2008
[CrossRef]
Yen YM, Kocher MS. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. Surgical technique. J Bone Joint Surg Am. 2008;90 Suppl 2 Pt 1:20-30. Erratum in: J Bone Joint Surg Am. 2008;90:1337.
2008
Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent MC, Sponseller PD. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop.2008;28:493-9.28493
2008
[CrossRef]
Fayssoux RS, Stankovits L, Domzalski ME, Guille JT. Fractures of the distal humeral metaphyseal-diaphyseal junction in children. J Pediatr Orthop.2008;28:142-6.28142
2008
[CrossRef]
Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am.2007;89:2369-77.892369
2007
[CrossRef]
Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med.2007;50:162-71, 171.e1.7.50162
2007
[CrossRef]
White BJ, Walsh M, Egol KA, Tejwani NC. Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations. A prospective randomized trial. J Bone Joint Surg Am.2008;90:731-4.90731
2008
[CrossRef]
Motta F, Stignani C, Antonello CE. Effect of intrathecal baclofen on dystonia in children with cerebral palsy and the use of functional scales. J Pediatr Orthop.2008;28:213-7.28213
2008
[CrossRef]
Motta F, Stignani C, Antonello CE. Upper limb function after intrathecal baclofen treatment in children with cerebral palsy. J Pediatr Orthop.2008;28:91-6.2891
2008
[CrossRef]
Senaran H, Shah SA, Presedo A, Dabney KW, Glutting JW, Miller F. The risk of progression of scoliosis in cerebral palsy patients after intrathecal baclofen therapy. Spine.2007;32:2348-54.322348
2007
[CrossRef]
Ginsburg GM, Lauder AJ. Progression of scoliosis in patients with spastic quadriplegia after the insertion of an intrathecal baclofen pump. Spine.2007;32:2745-50.322745
2007
[CrossRef]
Tsirikos AI, Lipton G, Chang WN, Dabney KW, Miller F. Surgical correction of scoliosis in pediatric patients with cerebral palsy using the unit rod instrumentation. Spine.2008;33:1133-40.331133
2008
[CrossRef]
Graham HK, Boyd R, Carlin JB, Dobson F, Lowe K, Nattrass G, Thomason P, Wolfe R, Reddihough D. Does botulinum toxin A combined with bracing prevent hip displacement in children with cerebral palsy and "hips at risk"? A randomized, controlled trial. J Bone Joint Surg Am.2008;90:23-33.9023
2008
[CrossRef]
Newman CJ, Kennedy A, Walsh M, O'Brien T, Lynch B, Hensey O. A pilot study of delayed versus immediate serial casting after botulinum toxin injection for partially reducible spastic equinus. J Pediatr Orthop.2007;27:882-5.27882
2007
[CrossRef]
Rogozinski BM, Davids JR, Davis RB, Christopher LM, Anderson JP, Jameson GG, Blackhurst DW. Prevalence of obesity in ambulatory children with cerebral palsy. J Bone Joint Surg Am.2007;89:2421-6.892421
2007
[CrossRef]
Sabharwal S, Badarudeen S, McClemens E, Choung E. The effect of circular external fixation on limb alignment. J Pediatr Orthop.2008;28:314-9.28314
2008
[CrossRef]
Krieg AH, Speth BM, Foster BK. Leg lengthening with a motorized nail in adolescents: an alternative to external fixators? Clin Orthop Relat Res.2008;466:189-97.466189
2008
[CrossRef]
Ofluoglu O, Davidson RS, Dormans JP. Prophylactic bypass grafting and long-term bracing in the management of anterolateral bowing of the tibia and neurofibromatosis-1. J Bone Joint Surg Am.2008;90:2126-34.902126
2008
[CrossRef]
Cho TJ, Choi IH, Lee KS, Lee SM, Chung CY, Yoo WJ, Lee DY. Proximal tibial lengthening by distraction osteogenesis in congenital pseudarthrosis of the tibia. J Pediatr Orthop.2007;27:915-20.27915
2007
[CrossRef]
Bernstein RM, Watts HG, Setoguchi Y. The lengthening of short upper extremity amputation stumps. J Pediatr Orthop.2008;28:86-90.2886
2008
[CrossRef]
Van Heest A, James MA, Lewica A, Anderson KA. Posterior elbow capsulotomy with triceps lengthening for treatment of elbow extension contracture in children with arthrogryposis. J Bone Joint Surg Am.2008;90:1517-23.901517
2008
[CrossRef]
Sinigaglia R, Gigante C, Bisinella G, Varotto S, Zanesco L, Turra S. Musculoskeletal manifestations in pediatric acute leukemia. J Pediatr Orthop.2008;28:20-8.2820
2008
[CrossRef]
Moser T, Giacomelli MC, Clavert JM, Buy X, Dietemann JL, Gangi A. Image-guided laser ablation of osteoid osteoma in pediatric patients. J Pediatr Orthop.2008;28:265-70.28265
2008
[CrossRef]
Arkader A, Dormans JP. Osteoblastoma in the skeletally immature. J Pediatr Orthop.2008;28:555-60.28555
2008
[CrossRef]
Wright JG, Yandow S, Donaldson S, Marley L; Simple Bone Cyst Trial Group. A randomized clinical trial comparing intralesional bone marrow and steroid injections for simple bone cysts. J Bone Joint Surg Am.2008;90:722-30.90722
2008
[CrossRef]
Basarir K, Piskin A, Güçlü B, Yildiz Y, Saglik Y. Aneurysmal bone cyst recurrence in children: a review of 56 patients. J Pediatr Orthop.2007;27:938-43.27938
2007
[CrossRef]
Lin PP, Brown C, Raymond AK, Deavers MT, Yasko AW. Aneurysmal bone cysts recur at juxtaphyseal locations in skeletally immature patients. Clin Orthop Relat Res.2008;466:722-8.466722
2008
[CrossRef]
Saavedra-Lozano J, Mejías A, Ahmad N, Peromingo E, Ardura MI, Guillen S, Syed A, Cavuoti D, Ramilo O. Changing trends in acute osteomyelitis in children: impact of methicillin-resistant Staphylococcus aureus infections. J Pediatr Orthop.2008;28:69-75.2869
2008
Gafur OA, Copley LA, Hollmig ST, Browne RH, Thornton LA, Crawford SE. The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines. J Pediatr Orthop.2008;28:777-85.28777
2008
[CrossRef]
Birmingham P, Helm JM, Manner PA, Tuan RS. Simulated joint infection assessment by rapid detection of live bacteria with real-time reverse transcription polymerase chain reaction. J Bone Joint Surg Am.2008;90:602-8. Erratum in: J Bone Joint Surg Am. 2008;90:1337.90602
2008
[CrossRef]
Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine toxicity in human articular chondrocytes. J Bone Joint Surg Am.2008;90:986-91.90986
2008
[CrossRef]
Nguyen AM, Johannessen W, Yoder JH, Wheaton AJ, Vresilovic EJ, Borthakur A, Elliott DM. Noninvasive quantification of human nucleus pulposus pressure with use of T1rho-weighted magnetic resonance imaging. J Bone Joint Surg Am.2008;90:796-802.90796
2008
[CrossRef]
Auerbach JD, Ahn J, Zgonis MH, Reddy SC, Ecker ML, Flynn JM. Streamlining the evaluation of low back pain in children. Clin Orthop Relat Res.2008;466:1971-7.4661971
2008
[CrossRef]
Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop.2008;28:230-3.28230
2008
[CrossRef]
Jarvis J, Garbedian S, Swamy G. Juvenile idiopathic scoliosis: the effectiveness of part-time bracing. Spine.2008;33:1074-8.331074
2008
[CrossRef]
Hunter LN, Sison-Williamson M, Mendoza MM, McDonald CM, Molitor F, Mulcahey MJ, Betz RR, Vogel LC, Bagley A. The validity of compliance monitors to assess wearing time of thoracic-lumbar-sacral orthoses in children with spinal cord injury. Spine.2008;33:1554-61.331554
2008
[CrossRef]
Bradley LJ, Ratahi ED, Crawford HA, Barnes MJ. The outcomes of scoliosis surgery in patients with syringomyelia. Spine.2007;32:2327-33.322327
2007
[CrossRef]
Qiu Y, Zhu Z, Wang B, Yu Y, Qian B, Zhu F. Radiological presentations in relation to curve severity in scoliosis associated with syringomyelia. J Pediatr Orthop.2008;28:128-33.28128
2008
[CrossRef]
Qiu Y, Wang S, Wang B, Yu Y, Zhu F, Zhu Z. Incidence and risk factors of neurological deficits of surgical correction for scoliosis: analysis of 1373 cases at one Chinese institution. Spine.2008;33:519-26.33519
2008
[CrossRef]
Schwartz DM, Auerbach JD, Dormans JP, Flynn J, Drummond DS, Bowe JA, Laufer S, Shah SA, Bowen JR, Pizzutillo PD, Jones KJ, Drummond DS. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am.2007;89:2440-9.892440
2007
[CrossRef]
Hsu B, Cree AK, Lagopoulos J, Cummine JL. Transcranial motor-evoked potentials combined with response recording through compound muscle action potential as the sole modality of spinal cord monitoring in spinal deformity surgery. Spine.2008;33:1100-6.331100
2008
[CrossRef]
Cheh G, Lenke LG, Padberg AM, Kim YJ, Daubs MD, Kuhns C, Stobbs G, Hensley M. Loss of spinal cord monitoring signals in children during thoracic kyphosis correction with spinal osteotomy: why does it occur and what should you do? Spine.2008;33:1093-9.331093
2008
[CrossRef]
Lieberman JA, Lyon R, Feiner J, Hu SS, Berven SH. The efficacy of motor evoked potentials in fixed sagittal imbalance deformity correction surgery. Spine.2008;33:E414-24.33E414
2008
[CrossRef]
Ward WT, Rihn JA, Solic J, Lee JY. A comparison of the Lenke and King classification systems in the surgical treatment of idiopathic thoracic scoliosis. Spine.2008;33:52-60.3352
2008
[CrossRef]
Patel PN, Upasani VV, Bastrom TP, Marks MC, Pawelek JB, Betz RR, Lenke LG, Newton PO. Spontaneous lumbar curve correction in selective thoracic fusions of idiopathic scoliosis: a comparison of anterior and posterior approaches. Spine.2008;33:1068-73.331068
2008
[CrossRef]
Kim YJ, Lenke LG, Bridwell KH, Cheh G, Whorton J, Sides B. Prospective pulmonary function comparison following posterior segmental spinal instrumentation and fusion of adolescent idiopathic scoliosis: is there a relationship between major thoracic curve correction and pulmonary function test improvement? Spine.2007;32:2685-93.322685
2007
[CrossRef]
Kim YJ, Lenke LG, Bridwell KH, Cheh G, Sides B, Whorton J. Prospective pulmonary function comparison of anterior spinal fusion in adolescent idiopathic scoliosis: thoracotomy versus thoracoabdominal approach. Spine.2008;33:1055-60.331055
2008
[CrossRef]
Hamzaoglu A, Ozturk C, Aydogan M, Tezer M, Aksu N, Bruno MB. Posterior only pedicle screw instrumentation with intraoperative halo-femoral traction in the surgical treatment of severe scoliosis (>100 degrees). Spine.2008;33:979-83.33979
2008
[CrossRef]
Watanabe K, Lenke LG, Bridwell KH, Kim YJ, Watanabe K, Kim YW, Kim YB, Hensley M, Stobbs G. Comparison of radiographic outcomes for the treatment of scoliotic curves greater than 100 degrees: wires versus hooks versus screws. Spine.2008;33:1084-92.331084
2008
[CrossRef]
Lehman RA Jr, Lenke LG, Keeler KA, Kim YJ, Buchowski JM, Cheh G, Kuhns CA, Bridwell KH. Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs: minimum three-year follow-up of one hundred fourteen cases. Spine.2008;33:1598-604.331598
2008
[CrossRef]
Howard A, Donaldson S, Hedden D, Stephens D, Alman B, Wright J. Improvement in quality of life following surgery for adolescent idiopathic scoliosis. Spine.2007;32:2715-8.322715
2007
[CrossRef]
Carreon LY, Puno RM, Lenke LG, Richards BS, Sucato DJ, Emans JB, Erickson MA. Non-neurologic complications following surgery for adolescent idiopathic scoliosis. J Bone Joint Surg Am.2007;89:2427-32.892427
2007
[CrossRef]
Upasani VV, Caltoum C, Petcharaporn M, Bastrom T, Pawelek J, Marks M, Betz RR, Lenke LG, Newton PO. Does obesity affect surgical outcomes in adolescent idiopathic scoliosis? Spine.2008;33:295-300.33295
2008
[CrossRef]
Auerbach JD, Lonner BS, Antonacci MD, Kean KE. Perioperative outcomes and complications related to teaching residents and fellows in scoliosis surgery. Spine.2008;33:1113-8.331113
2008
[CrossRef]
Sucato DJ, Lovejoy JF, Agrawal S, Elerson E, Nelson T, McClung A. Postoperative ketorolac does not predispose to pseudoarthrosis following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Spine.2008;33:1119-24.331119
2008
[CrossRef]